Allen, Timothy NEW YORK STATE DEPARTMENT OF HEALTH , k. t Z
Vital Records Section Burial - Transit Perm'
Name First Middle Last Sex
Timothy W Allen Male
li
f Date of Death Age If Veteran of U.S. Armed Forces,
11/16/2018 48 Years War or Dates
t. Place of Death Hospital, Institution or
•`i City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Undetermined Pending
4"4 Q Natural Cause Accident Homicide Suicide [�
t ° Circumstances Investigation
Medical Certifier Name Title
(',° Asim Chaudry MD
Address
, 100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
rc.y. City, Town or Village Glens Falls 5601 544
0Burial Date Cemetery or Crematory
.7 11/19/2018 Pineview Crematory
`` .[]Entombment
Address
t®Cremation Queensbury, New York
Date l Place Removed
❑Removal 1 and/or Held
_ and/or Address
Hold
Date Point of
[i Transportation Shipment
by Common Destination
Carrier
Disinterment
Date Cemetery Address
Reinterment
iji
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home Inc 00448
vi
Address
7 Sherman Ave,Corinth,New York 12822
4 Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
1-3 Date Issued 11/19/2018 Registrar of Vital Statistics Robert A Curtis(EtectronicatlySigned)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
�� G
Date of Disposition dill iii Place of Disposition .-i rr.a,(U-
(address)
(section) A (lot number) (grave number)
. Name of Sexton or Person in Charge of Pr mises `r on c,- 'N'"x
r' (p se p 0
Signature d Title / 4flI-
(over)
DOH-1555 (02/2004)